Coronial

191 results for acute kidney injury

VIChospital2014-12-16

Finding into death of Michael Justin Nicoll

36y · Male·Multiorgan failure complicating Streptococcus pyogenes septicaemia

Michael Nicoll, 36, presented to Cabrini Hospital ED with diarrhoea, vomiting, and dehydration. Dr P. diagnosed gastroenteritis and discharged him after IV fluids, despite dehydration, tachycardia, elevated creatinine, a…

emergency medicineintensive carediagnosticsystemondansetron
VICaged care2019-02-21

Finding into death of Kathleen Schleibs

88y · Female·Sepsis complicated by multiple organ failure in a woman with comorbidities in th…

…acement of an indwelling catheter. Critical failures included: inadequate assessment before discharge from acute care despite uncontrolled pain and ongoing opioid toxicity; discharge to a low-care facility unable to pro…

orthopaedic surgerygeriatric medicinediagnosticcommunicationfentanyl
QLDhospital2017-08-29

Mr C - Non-inquest findings

87y · Male·Endobronchial and pulmonary haemorrhage secondary to pneumonia complicating chro…

An 87-year-old man with atrial fibrillation on warfarin underwent elective bronchoscopy for suspected lung lesion. The admitting respiratory team incorrectly documented a mechanical aortic valve replacement when he actua…

respiratory medicinecardiologydiagnosticcommunicationwarfarin
QLDhospital2018-07-09

AD - Non-inquest findings

75y · Male·Multi-organ failure secondary to cardiogenic shock and anterior myocardial infar…

A 75-year-old man presented to a tertiary hospital ED with acute anterior STEMI but diagnosis was delayed by approximately 10 hours. The first hospital ECG at 6:47am showe…

emergency medicinecardiologydiagnosticcommunicationmorphine
WAhospital2013-11-12

Inquest into the Death of Ford, Valma May Ruth

77y · Female·Complications following a recent fracture and surgical repair of the right hip i…

A 77-year-old woman with complex comorbidities (atrial fibrillation, aortic stenosis, chronic renal impairment, emphysema) on Warfarin sustained a femur fracture and underwent ORIF on day 3 of admission (19 Nov 2009). Ke…

orthopaedic surgeryemergency medicinediagnosticsystemwarfarin
NSWhospital2025-08-14

Inquest into the death of Wilfred Whippy Williams

45y · Male·Diabetic ketoacidosis with multi-organ failure caused by pneumonia

A 45-year-old Aboriginal man with poorly managed diabetes and schizophrenia presented to Cowra District Hospital ED with lethargy, cough and fever. Despite being triaged as category 2 (urgent) with abnormal vital signs i…

emergency medicineendocrinologycommunicationdiagnosticmetformin
QLDhospital2017-10-17

SWK - Non inquest findings

78y · Female·multi-organ failure due to haemorrhage into the abdomen, pelvis and retroperiton…

78-year-old Jehovah's Witness died from multi-organ failure secondary to intra-abdominal and retroperitoneal haemorrhage following extensive anterior and posterior lumbar spinal fusion surgery. The patient had multiple c…

spinal surgeryorthopaedic surgeryproceduraldiagnosticaramine
QLDhospital2016-03-18

McGuane, Shirley Fay - Non-inquest findings

84y · Female·Myocardial infarction

Shirley McGuane, 84, died from myocardial infarction following elective proctocolectomy. Post-operative care was deficient: chest pain on day 2 post-op with ECG showing atrial fibrillation and new right bundle-branch blo…

surgerycardiologydiagnosticcommunicationwarfarin
TAShospital2017-09-22

Coroner's Finding: Hosking, Jason Mathew Henry

34y · Male·Staphylococcus aureus sepsis and endocarditis

Jason Hosking, 34, presented to ED with vomiting, diarrhoea, fever, tachycardia and hypotension on 10 November 2014. Blood tests by 11.23am showed markedly elevated inflammatory markers (CRP 234.3, neutrophils 10.8, elev…

emergency medicinemicrobiologydiagnosticcommunicationoxycodone
QLDaged care2024-09-19

Non-inquest findings - a resident

85y · Male·Heat stroke

An 85-year-old man with dementia, diabetes, and aortic stenosis died from heat stroke after spending 2 hours 18 minutes unmonitored in an unsheltered outdoor garden area at a residential aged care facility. The resident …

geriatric medicineemergency medicinesystemcommunication
TAS2022-04-29

Coroner's Finding: Lavoipierre, Andre Marc

41y · Male·exsanguination (hypovolemic shock complicating acute blood loss) due to fistula …

Andre Marc Lavoipierre, age 41, died on 26 June 2019 from exsanguination due to internal bleeding (ureter-iliac artery fistula or steady renal/bladder bleed). He fell at his supported residential unit on the morning of d…

psychiatrygeneral practicecommunicationdelayfluoxetine
QLDhospital2025-10-01

Non-inquest findings into the death of Mr S

26y · Male·Multi-organ failure due to pneumococcal septic shock

A 26-year-old man presented with chest and abdominal pain, initially diagnosed with possible hepatitis based on elevated liver function tests. He developed an atypical blanched rash not recognised as varicella zoster (ch…

emergency medicineinfectious diseasesdiagnosticdelayantacid
VIChospital2024-09-26

Finding into death of FH C

11y · Male·Sepsis

An 11-year-old boy with autism spectrum disorder (ASD level 3), ADHD, and obesity died from sepsis on 20 June 2022. He presented to Rosebud Hospital ED on 14 June with fever, vomiting, and low blood pressure, was dischar…

emergency medicinepaediatricsdiagnosticcommunicationrisperidone
QLDhospital2007-12-07

Burgen, Deborah Denise

49y · Female·Intra-abdominal haemorrhage, septic and haemorrhagic shock as a result of a lapa…

…t definitive diagnosis or treatment. Critical failures included: failure to adequately triage and admit an acutely unwell patient; delay in operating until bowel perforation occurred; inadequate post-operative monitorin…

emergency medicinesurgerydiagnosticdelayparacetamol/codeine
QLDhospital2018-04-12

Mr RR - Non-inquest findings

86y · Male·Aspiration Pneumonia secondary to Recurrent Colorectal Carcinoma

An 86-year-old man died from aspiration pneumonia following bowel preparation for elective colonoscopy. He was admitted to an outlying ward rather than the gastroenterology unit, where nursing staff documented multiple e…

gastroenterologycardiologydiagnosticcommunicationondansetron
SAhospital2008-08-22

Coroner's Finding: CARTER Kenneth Morton

76y · Male·ruptured abdominal aortic aneurysm

Kenneth Carter, 76, died from a ruptured abdominal aortic aneurysm (AAA) on 8 June 2005. He had presented to Flinders Medical Centre Emergency Department on 1 June 2005 with back pain, hypotension (90/65 mmHg), and two e…

emergency medicinegeneral medicinediagnosticsystemwarfarin
VIChospital2013-07-29

Finding into death of Beverley Pattinson

70y · Female·Severe dehydration and renal complications secondary to intestinal obstruction d…

A 70-year-old woman presented to a rural hospital with 48 hours of vomiting and dehydration secondary to an inguinal hernia obstruction. The initial assessment by the hospital medical officer failed to adequately review …

emergency medicinegeneral practicediagnosticcommunicationmetoclopramide
QLDrural hospital2020-05-08

FD - Non-inquest findings

68y · Female·Sepsis (Enterobacter cloacae) due to peritonitis as a consequence of leaking per…

A 68-year-old woman with oculopharyngeal muscular dystrophy died from sepsis due to peritonitis following dislodgement of a PEG tube inserted on 27 February 2018. She presented to a rural hospital 5.5 hours post-discharg…

gastroenterologyemergency medicinediagnosticcommunicationaugmentin duo
VIChospital2014-02-05

Finding into death of Margareta Snopek

67y · Female·Lithium toxicity with chest infection and bipolar disorder; Alzheimer's disease …

Mrs Snopek, aged 67 with bipolar disorder on long-term lithium, was prescribed coversyl (an ACE inhibitor) by Dr A. in January 2008 for hypertension. This combination is contraindicated as ACE inhibitors impair renal fun…

general practiceneurologymedicationdiagnosticlithium carbonate
WAaged care2023-10-11

Inquest into the Death of Kathryn PAPANASTASIOU

74y · Female·Fractures of the legs, with terminal palliative care, in an elderly lady with mu…

Ms Papanastasiou, a 74-year-old aged care resident confined to a wheelchair, died from bilateral femoral fractures sustained when she fell from her wheelchair during sudden bus braking. The wheelchair was secured using o…

geriatric medicineorthopaedic surgerysystemprocedural

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